MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
The primary goal of the Case Manager is to optimize members’ health care and delivery of care experience with expected cost savings due to improved quality of care. This is accomplished through engagement and understanding of the member’s needs, environment, providers, support system and optimization of services available to them. Case Manager is expected to assess and evaluate member’s needs, be a creative, efficient and resourceful problem solver. This will be accomplished through in field work in member’s homes, facilities, provider offices and community resources. The Case manager serves as member’s advocate and accompanies the member throughout their care journey in the field.
Case Manager is monitored and assessed based on value added to improved health status of member. That includes, but not limited to their disease management physical and behavioral, medication adherence, and utilization of emergency services, hospitalizations and avoidable complications. Case Manager’s primary role is to support members in need and problem solve issues in a beneficial manner for the member and Plan. The support is comprehensive and includes clinical, social, financial, environmental and safety aspects.
This is a hands on, involved, predominately field based position and will require travel within the MetroPlus Health Plan service area.
Physically meet the members where they are to gain deep understanding of their situation and needs
Problem solve member’s problems and needs: clinical, psychosocial, financial, environmental
Provide services to members of varying age, clinical scenario, culture, financial means, social support, and motivation
Engage members in a collaborative relationship, empowering them to manage their physical, psychosocial and environmental health to improve and maintain lifelong well being
Assess risks and gaps in care
Maximize member’s access to available resources
Prepare member oriented plan of care with member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices
Communicate plan of care to Primary Care Physician initially and no less than monthly with updates
Insure member caregiver understanding as it relates to language barriers, stress reaction or cognitive limitations/barriers using verbal and nonverbal techniques
Train member on relevant chronic diseases, preventive care, medication management (medication adherence), home safety, etc.
Provide Complex care management including but not limited to; insuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
Advocate for members by assisting them to address challenges, and make informed choices regarding clinical status and treatment options
Develop collaborative relationships with clinical providers and facility staff
Employ critical thinking and judgment when dealing with unplanned issues
Ability to use data as a tool in tracking and trending outcomes and clinical information
Maintain accurate, comprehensive and current clinical and non-clinical documents
Comply with all orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures, and actively participate in evaluation process
Maintain professional competencies as a Case Manager
Other duties as assigned by Manager.
Clinical background: LMSW or LCSW
Masters Degree required
Field experience providing care management or care coordination required, managing both medical and psychosocial needs of clients
Prior experience in Case Management in a health care and/or Managed Care setting strongly preferred
Proficiency with computers navigating in multiple systems and web based applications
Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
Time management and organizational skills
Strong problem solving skills
Ability to prioritize and manage changing priorities under pressure
Must know how to use Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
Ability to proficiently read and interpret medical records, claims data, pharmacy and lab reports, and prescriptions required
Ability to travel within the MetroPlus service area making home visits to members, facility visits to clinical providers, and visits to community, faith and other social service based agencies.
Ability to work closely with member and caregiver.
Ability to form effective working relationships with a wide range of individuals.
Licensure and/or Certification Required
LMSW/LCSW with current NYS license
Integrity and Trust